Improving Patient Access in Neuro-Interventional Ultrasound

Streamlining Patient Access NEURO NEURO- -INTERVENTIONAL INTERVENTIONAL ULTRASOUND ULTRASOUND IBI IBI OPUIYO,RDMS OPUIYO,RDMS JOSEPH STEELE STEELE,MD EXECUTIVE SPONSOR EXECUTIVE SPONSOR - - JOSEPH ,MD

The project was a collaboration with ICCE, OPI, NIR Ultrasound technologists, nurses and faculty

Neuro-Interventional Ultrasound Provide ultrasounds of the thyroid and neck regions Referrals from various clinics throughout the institution including Endocrine, Melanoma, Head and Neck Surgery, and Lymphoma services Number of completed patient exams in NIR US has grown in 5 year period from just over 4,000 in FY06 to 10,000 exams and biopsies in FY11

PROBLEM PROBLEM

Who Is Impacted ? Head and Neck Surgery Endocrine Thoracic NIR Other Referring Services Melanoma PATIENTS

NIR US Project Goal Decrease Delays Increase Access

NIR will decrease the number of days for referring clinics to obtain diagnostic scans for AIM patients from 25 or more working days to less than 5 days by June 2011.

IDENTIFYING & ASSESSING CAUSE ANALYSIS CAUSE ANALYSIS

Scheduling Environment Procedures CLINIC HOURS OF OPERATION 8-4PM Nursing documentation take time Limited slots for clinics 6SCAN ROOMS,TECHS Multiple BXs @ once Congestionof appts. CertainUS rooms are only used for scanning Wait for requesting MD to reply Allotted exam times: SCANS:1HOUR BX: 2 HOURS PATIENT SCHEDULING Floor Plan Issue: Waitingarea, holding area, and US rooms are far apart Waitfor BX result and DIA to set up Limited Patient Access to NIR Diagnostic Scans and Procedures WORKFLOW Dictation between patients Checkin early and want to be seen early TEMPLATE Conferences and meetings Arrivelate (weather, traffic and other appts . Adding patients without verifying current schedule No show Lost in the hospital Double duties Anxietyinduce HTN Patients PERSONNEL CAUSE ANALYSIS

KEY ISSUES KEY ISSUES SCHEDULING LIMITATIONS OPERATIONS PROCESSES WORKFLOW

PERFORMANCE ASSESSED BASELINE DATA BASELINE DATA

Capacity Backlog : Scheduling Max 38 potential appointment slots/day 25 day delay for next available appointment

Process Analysis: Scheduling Issue: limited appointment slots available

Operations: Processes Workflow Personnel Situational Processes Practical Processes

Operations: Asset Utilization PRE TEMPLATE ROOM UTILIZATION HIGH VOLUME DATES NUMBER OF PROCEDURES BEGIN TO LEAVE DEPT. 1/21/2011 1/24/2011 1/27/2011 1/31/2011 2/7/2011 2/9/2011 2/11/2011 2/15/2011 2/25/2011 2/28/2011 3/2/2011 3/4/2011 3/8/2011 3/9/2011 3/16/2011 3/23/2011 3/28/2011 3/29/2011 3/30/2011 4/1/2011 4/5/2011 49 44 44 52 44 50 46 47 48 49 49 45 47 54 75.41 55.37 68.72 66.6 43.7 60.92 71.43 57.67 75.37 65.71 66.58 74.96 49.02 64.81 57.49 56.17 45.86 62.59 58.91 52.69 55.11 46 48 46 53 49 44 45 AVERAGE TIME IN MINUTES 47.57 61.19 Pre Template Room utilization 80 Average time in Rooms 70 60 50 40 30 20 10 0 40564 40567 40570 40574 40581 40583 40585 High Volume Dates 40589 40599 40602 40604 40606 40610 40611 40618 40625 40630 40631 40632 40634 40638

PHASED APPROACH INTERVENTIONS INTERVENTIONS

Phase I Feb 1, 2011 to March 10, 2011 SCHEDULE Management team began complete restructuring of scheduling template Opening of initial set of additional scheduling slots for servicing clinics. This addressed immediate bottleneck issues. OPERATIONS Personnel changes to accommodate expanded schedule. 1. New technologist schedule 2. New temporary Imaging Assistant

Phase II March 11, 2011 to April 14, 2011 SCHEDULE Process changed for ordering diagnostic scans/biopsies Communications and education of referring service Clinical Coordinators on forthcoming schedule template usage OPERATIONS Departmental operational hours expanded

Phase III April 15,2011 to July 15, 2011 Go Live: opening of restructured scheduling template Data gathered for 90 day assessment of combined changes

Results The success of the project was measured using two metrics The number of available daily slots for procedures or scans. The time to next appointment for a diagnostic ultrasound and biopsy

The data reveals that measured improvements are attributed to : SCHEDULE The new scheduling template

Available appointment slots increased from 38 to 55 NIR Clinical Operations Report Summary Template Timeslots Available Jan. Feb. March April May June July Scan w/biopsy timeslots 10 10 10 14 16 16 16 Scan only timeslots 18 18 23 24 25 25 25 Overbook timeslots 10 10 10 12 14 14 14 Total Timeslots 38 38 43 50 55 55 55

Results Scheduling Template Scheduling Template NUMBER OF WORKDAYS FOR NEXT AVAILABLE APPOINTMENT 80 70 60 # WORKDAYS 50 40 Scan/Biopsy Overbook Scan/Biopsy Template 30 Scan Only Overbook Scan Only Template 20 10 0 WORK WEEK

The data reveals that measured improvements are attributed to : OPERATIONS Pre assessments Extended department hours of operation Change in personnel (tech/MD) schedules Additional Imaging Assistant (personnel changes) New lead technologist role

AVERAGE TIME IN MINUTES: Pre Template Post Template 61.19 minutes 54.63 minutes Room utilization improved. The time to perform one complete procedure (time from patient entering the room to exiting the room) decreased 6.6 minutes. 90 Day NIR Room Utilization Times 80 Room Usage Per Patient 70 60 Seen in Minutes Pre Template Room Utilization Times Jan 2011- Apr 2011 Post Template Room Utilization Times Apr 2011- July 2011 50 40 30 20 10 0 90 Day Period

Calculation Summary / ROI Year 0 Year 1 Year 2 Year 3 Cost of Capital Investments/Costs Benefit/Revenue Annual Net Benefit/Revenue(Costs) 9.20% (3,906) 0 0 0 120,919 120,919 120,919 120,919 120,919 120,919 (3,906) Benefit/Revenue Including Soft Savings Annual Net Benefit (Costs) Including soft Savings 120,919 120,919 120,919 (3,906) 120,919 120,919 120,919 Risk Adjusted ROI = Net Present Value of Cumulative Net Benefit / Net Present Value of Total Costs RA ROI (Margin for yrs 1-3 discounted @ Cost of Capital %) Net Present Value Internal Rate of Return (Expected Return) 6959% $275,722.78 3096%

NEXT STEPS NEXT STEPS

Thank You NIR US Process Improvement Teams NIR US Manager Tonya Brightmon Executive Sponsor Dr. Steele